Patient Satisfaction Survey printable pdf download

Patient Satisfaction Survey

In order to find out how we are meeting your needs, we are asking our patients a few questions about

the care they have received. Please be honest in your answers. Your comments will be held in strict

confidence and you do not have to sign your name unless you want to. We plan to use your

suggestions to make our service to you and your family even better. Thank you for your comments.

Please complete items 1 - 4 to describe yourself:

1. Age

! 18-25

! 26-40

! 41-55

! over 55

2. Gender

! Male

! Female

3. The number of visits I have made to the office in the past year is:

! 1

! 2

! 3

! 4

! 5 or more

! My treatment

! My child's treatment was:

! completed

! not completed

The list below includes statements about the care you received at our office.

Please place a check mark under the column to indicate whether you agree, disagree or are not sure

about each one. Please explain the ones you disagree with next to "Comments."

Appointments

Agree

Unsure Disagree

"# It was easy to make my first appointment.

"# The appointment secretary (coordinator) was polite and helpful.

"# I received a reminder of each of my appointments.

"# It was easy to schedule a convenient appointment.

"# Appointment options were given that suited my schedule.

"# I was seen on time for my appointments; if not, I was given a reason for the

delay.

Comments:_________________________________________________________________________

Facilities

Agree

Unsure Disagree

"# The office location and parking were convenient.

"# The reception area was neat and clean.

"# The equipment was clean and presentable.

"# The temperature in the office was comfortable.

"# The lighting in the office was sufficient.

"# The music in the office was pleasant.

Comments: ________________________________________________________________________

Patient Satisfaction Survey

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